How Monitoring Patients Post-Discharge Reduces Hospital Readmissions

by Jill Reeves, MHA on Mar 13, 2017


In the past, when hospitals discharged a patient to the next level of care—whether it was to a post-acute facility or directly home—they stopped monitoring the patient’s treatment, condition and outcomes—sending the individual to their next destination and moving on to the next patient in crisis.

However, times have changed. Hospitals and health systems are now held accountable for readmissions up to 90 days after discharge, and need to keep a closer eye on patients after they leave the hospital, engaging with them to ensure care continuity and mitigate readmission risk. If they don’t, there could be severe financial consequences along with dissatisfied patients.


Why is it difficult to track patients after they’re discharged?

The challenge with tracking patients post-discharge is the sheer size and scope of the effort. Some hospitals release hundreds of patients per day, and communicating with each of them can be challenging. To make the task more manageable, hospitals are starting to focus on those patients who are at greater risk for readmission, such as those with multiple comorbidities, limited family support, or a history of non-compliance with treatment plans or medication.


Benefits of Care Technology

Even if an organization focuses on high-risk patients, the monitoring process can still be time-consuming and resource intensive. This is where technology can help. By leveraging care coordination solutions a hospital can efficiently and effectively match a patient with the ideal post-acute provider that is fully equipped to meet the patient’s needs. Using the solution, the hospital can transfer necessary treatment information to the post-acute provider before the patient arrives onsite, ensuring the receiving organization obtains all of the crucial information it needs to best treat the incoming patient.

Reduce Readmission with Transportation - Learn How

For those high-risk patients discharged home, technology can again be of help. Hospitals can leverage Bluetooth-enabled equipment in conjunction with care management apps to track a patient’s health indicators and treatment plan compliance. For example, every time the patient uses a piece of equipment, such as a blood pressure cuff or scale, the readings automatically upload to the hospital for review. If the patient skips a reading or the equipment shows a worrisome trend, the hospital can assess the need for intervention. Similarly, if a patient skips a follow-up appointment, the hospital can reach out to the patient and family using the care management app to determine what’s going on.

Although reducing readmissions can be a complex task, organizations that focus on high-risk patients and implement the proper technology solutions will go a long way toward reducing unnecessary readmissions and providing better patient care.


To learn more about how care coordination technology can mitigate the risk for patient readmission, subscribe to our knowledge center and get ongoing insights! 

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Meet the Author

Jill Reeves has over 30 years of experience in the healthcare industry and has worked exclusively in the fields of market research, statistical analysis and healthcare interactive/digital marketing. Before joining CQuence Health Group as marketing manager, Jill was director of communications and new media for PRC, a nationwide healthcare market research organization. Jill earned a master's degree in healthcare administration from Bellevue University and a bachelor's degree in education from the University of Nebraska in Kearney. She is a published author and avid student of social media and emerging communication trends.